Which Patients with Low-Risk Prostate Cancer are Still Receiving Radical Prostatectomy? Impact of Patient Selection on Inverse Stage Migration at Two European, Tertiary Referral Centers

Introduction & Objectives: The increasing use of conservative approaches such as active surveillance in selected patients with low-risk prostate cancer (PCa) substantially reduced the proportion of patients with favourable disease characteristics undergoing radical prostatectomy (RP). We sought to describe the stage migration phenomenon towards more aggressive disease characteristics in patients treated with RP in more recent years. Materials & Methods: We evaluated 17,091 patients treated with radical prostatectomy (RP) at two European tertiary referral centers between 2006 and 2016. Among those, 4822 patients were classified as low-risk according to the European Association of Urology risk classification (cT1/ T2a, Gleason 6, PSA). Results: The proportion of patients with low-risk disease significantly decreased according to the year of surgery and ranged between 67.1% to 17.6% in the years 2006 and 2017, respectively (p\u3c0.001). Among low risk patients, patient age decreased from 63.8 to 61.8 years between 2006 and 2017 (p\u3c0.001). Median PSA at diagnosis increased from 5.52 ng/mL in 2006 to 6.32 ng/mL in 2016 (p\u3c0.001). The proportion of positive biopsy cores increased from 29.3% in 2006 to 31.6% in 2016 (p\u3c0.001). Overall, 4,469 (92.7%) and 353 (7.3%) had clinical T1 and T2a disease, respectively. The prevalence of individuals with clinical T2a disease increased from 7.6% in 2006 to 11.8% in 2016 (p=0.04). Similarly, the rate of low risk individuals with ≥pT3b/4 disease increased from 1.2% in 2006 to 4.1% in 2016 (p=0.01). The rate of upgrading at final pathology increased from 41.6% in 2006 to 80.5% in 2016 (p\u3c0.001). The use of PLND increased from 20.6% in 2006 to 61.5% in 2016 (p\u3c0.001). Multivariable Cox regression-derived 5-year BCR rates increased from 8.2% in 2006 to 10.4% in 2016 (p\u3c0.01). Conclusions: Contemporary low risk RP patients have higher PSA, clinical stage and proportion of positive cores, as well as a higher risk of upgrading (80%) and pT3b/4 disease at final pathology. This translated into higher recurrence rates in more recent years. These results support the notion that not all low risk PCa patients have favourable pathological outcomes and indicate a more accurate patient selection where contemporary men with low risk PCa considered for surgery are those with more adverse cancer profiles